Avoiding premedication in children a practical approach

Transcription

1 Preoperative preparation and communication in children Avoiding premedication in children a practical approach J. Berghmans M.D. Department of Anesthesia, ZNA Middelheim, Queen Paola Children s Hospital, Antwerp, Belgium Departments of Child and Adolescent Psychiatry/Psychology & Anesthesia, Erasmus University Medical Centre - Sophia Children s Hospital, Rotterdam, The Netherlands 11/01/2017 UZ Leuven December 1

2 Why is perioperative distress, anxiety and fear so important? managing an uncooperative frightened child at induction is distressing associated with postoperative behavioral changes influence on subjective perception and associated with higher levels of postoperative pain poor compliance with future medical therapy neuroendocrine changes Kain, et al. Anesth Analg 2004 Bringuier, et al. Anesth Analg 2009 Kain, et al. Pediatrics 2006 Proczkowska-Bjorklund, et al. J Child Health Care 2010 Davidson, et al. Curr Opin Anaesthesiol /01/2017 UZ Leuven December 2

3 Why is perioperative distress, anxiety and fear so important? Frequent! 40% some distress behavior 17% significant distress 33% efforts to escape Chorney, et al. Anesth Analg 2009 Davidson, et al. Curr Opin Anaesthesiol /01/2017 UZ Leuven December 3

4 We should not only focus on the induction! 11/01/2017 UZ Leuven December 4

5 CHILD - risk factors age attachment and separation trait anxiety temperament / personality emotional-behavioral functioning cognitive development and understanding of illness quality of previous medical encounters Davidson AJ et al. Paediatric anaesthesia 2006 Kain, et al. Arch Pediatr Adolesc Med 1996 Kain, et al. Anesthesiol Clin North America 2005 Berghmans, et al. Minerva Anestesiol /01/2017 UZ Leuven December 5

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7 CHILD - risk factors age attachment and separation trait anxiety temperament / personality emotional-behavioral functioning cognitive development and understanding of illness quality of previous medical encounters Davidson AJ et al. Paediatric anaesthesia 2006 Kain, et al. Arch Pediatr Adolesc Med 1996 Kain, et al. Anesthesiol Clin North America 2005 Berghmans, et al. Minerva Anestesiol /01/2017 UZ Leuven December 7

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9 CHILD - risk factors age attachment and separation trait anxiety temperament / personality emotional-behavioral functioning cognitive development and understanding of illness quality of previous medical encounters Davidson AJ et al. Paediatric anaesthesia 2006 Kain, et al. Arch Pediatr Adolesc Med 1996 Kain, et al. Anesthesiol Clin North America 2005 Berghmans, et al. Minerva Anestesiol /01/2017 UZ Leuven December 9

10 CHILD - risk factors age attachment and separation trait anxiety temperament / personality emotional-behavioral functioning cognitive development and understanding of illness quality of previous medical encounters Davidson AJ et al. Paediatric anaesthesia 2006 Kain, et al. Arch Pediatr Adolesc Med 1996 Kain, et al. Anesthesiol Clin North America 2005 Berghmans, et al. Minerva Anestesiol /01/2017 UZ Leuven December 10

11 CHILD - risk factors age attachment and separation trait anxiety temperament / personality emotional-behavioral functioning cognitive development and understanding of illness quality of previous medical encounters Davidson AJ et al. Paediatric anaesthesia 2006 Kain, et al. Arch Pediatr Adolesc Med 1996 Kain, et al. Anesthesiol Clin North America 2005 Berghmans, et al. Minerva Anestesiol /01/2017 UZ Leuven December 11

12 CHILD - risk factors age attachment and separation trait anxiety temperament / personality emotional-behavioral functioning cognitive development and understanding of illness quality of previous medical encounters Davidson AJ et al. Peadiatric anaesthesia 2006 Kain, et al. Arch Pediatr Adolesc Med 1996 Kain, et al. Anesthesiol Clin North America 2005 Berghmans, et al. Minerva Anestesiol /01/2017 UZ Leuven December 12

13 CHILD - risk factors age attachment and separation trait anxiety temperament / personality emotional-behavioral functioning cognitive development and understanding of illness quality of previous medical encounters Davidson AJ et al. Paediatric anaesthesia 2006 Kain, et al. Arch Pediatr Adolesc Med 1996 Kain, et al. Anesthesiol Clin North America 2005 Berghmans, et al. Minerva Anestesiol /01/2017 UZ Leuven December 13

14 Parent risk factors trait / state anxiety monitors / blunters socio-economic status gender cultural differences Davidson AJ et al. Paediatric anaesthesia /01/2017 UZ Leuven December 14

15 Parent risk factors trait / state anxiety monitors / blunters socio-economic status gender cultural differences Davidson AJ et al. Paediatric anaesthesia /01/2017 UZ Leuven December 15

16 Parent risk factors trait / state anxiety monitors / blunters socio-economic status gender cultural differences Davidson AJ et al. Paediatric anaesthesia /01/2017 UZ Leuven December 16

17 Parent risk factors trait / state anxiety monitors / blunters socio-economic status gender cultural differences Davidson AJ et al. Paediatric anaesthesia /01/2017 UZ Leuven December 17

18 Parent risk factors trait / state anxiety monitors / blunters socio-economic status gender cultural differences Davidson AJ et al. Paediatric anaesthesia /01/2017 UZ Leuven December 18

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20 11/01/2017 By Kevinbercaw - Own work, CC BY-SA 3.0, UZ Leuven December 20

21 Human behavior is complex Expression of perioperative distress, anxiety and fear can be verbal or behavioral, subtle or extreme 11/01/2017 UZ Leuven December 21

22 11/01/2017 UZ Leuven December Chorney, et al. Anesth Analg

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24 Behavior profiles by child age 11/01/2017 UZ Leuven December 24

25 How to assess perioperative anxiety? self-report (STAIC) measures of cooperation (ICC) physiological measures observer measures modified Yale Preoperative Anxiety Scale m-ypas development of a short version of the modified Yale Preoperative Anxiety Scale m-ypas-sf Kain, et al. Anesth Analg 1997 Jenkins, et al. Anesth Analg 2014 Caldwell-Andrews, et al. Anesthesiology /01/2017 UZ Leuven December 25

26 The modified Yale Preoperative Anxiety Scale (m-ypas) Five behavior categories activity emotional expressivity state of arousal vocalisation use of m-ypas-sf parents Kain, et al. Anesth Analg 1997 Jenkins, et al. Anesth Analg /01/2017 UZ Leuven December 26

27 Perioperative Adult Child Behavioral Interaction Scale (PACBIS) Sadhasivam, et al. Anesth Analg /01/2017 UZ Leuven December 27

28 Health care provider risk factors adult behavior affect children s distress 11/01/2017 UZ Leuven December 28

29 Health care provider risk factors Essential to understand non-verbal expressions and actions of the child toddler preschool aged children school aged children adolescent One person should talk rather than several people all talking at the same time 11/01/2017 UZ Leuven December 29

30 Health care provider risk factors reassuring comments empathic comments give the child too much control criticism apology Distress promoting behavior distracting behavior humor non-procedure related talk Coping promoting behavior Caldwell-Andrews, et al. Anesthesiology 2005 Martin, et al. Anesthesiology /01/2017 UZ Leuven December 30

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32 What can be done to relieve distress, anxiety and fear? Interventions educational behavioral alternative pharmacological 11/01/2017 UZ Leuven December 32

33 Educational interventions 11/01/2017 UZ Leuven December 33

34 Preparation appears to be a simple concept: to tell the child and parent, what is going to happen In reality, however, preparation is not so simple! What information, when and how it is provided and by who, are all key factors Coping skills > modeling > play therapy > operating tour > printed material Jaaniste, T., et al. Behav Res Ther /01/2017 UZ Leuven December 34

35 Educational interventions preparation programs / information (relaxation, coping, distraction, desensitization, role rehearsal, narrative information) age-appropriate needs (f.i. children 6 yr) negative behavior (f.i. children 3 yr) previous experience! should also be directed to parents Kain, Z. N. et al. Anesthesiol Clin North America /01/2017 UZ Leuven December 35

36 Behavioral interventions 11/01/2017 UZ Leuven December 36

37 The child 11/01/2017 UZ Leuven December 37

38 Anxiety reduction Distraction Video modeling Adding parents No excessive reassurance Coaching Exposure and shaping Kain, et al. Anesthesiology 2007 Cuzzocrea, et al. Pediatr Anesth 2013 Fortier, et al. Br J Anaesth /01/2017 UZ Leuven December 38

39 Effective! High cost! 11/01/2017 UZ Leuven December 39

40 Shaping and exposure (i.e. practise with the anesthesia mask) and parental use of distraction in the surgical setting 11/01/2017 UZ Leuven December 40

41 The Parent 11/01/2017 UZ Leuven December 41

42 Parental presence at induction experimental evidence does not support the routine use of parental presence (past versus new research) recent systematic review Not helpful? but it increases parental satisfaction respect to the child and parental rights and it should be allowed Manyande, et al. Cochrane Database Syst Rev 2015 Rosenbaum, et al. Pediatric Anesthesia /01/2017 UZ Leuven December 42

43 Parental presence at induction conflicting data! dependent on parental personality extremely context sensitive (cultural, religious, ethnic differences) (studies US vs non-us countries) Manyande, et al. Cochrane Database Syst Rev 2015 Rosenbaum, et al. Pediatric Anesthesia 2009 Wright, et al. Can J Anaesth /01/2017 UZ Leuven December 43

44 Parental presence at induction Preparing parents to be present for their child s anesthesia induction: a randomized controlled trial More self-efficacy about their role in the OR Audiovisual aid viewing immediately before pediatric induction moderates the accompanying parents anxiety Moderates the increase in anxiety associated with the anesthetic induction of their child Bailey, et al. Anesthesia & Analgesia 2015 Berghmans, et al. Paediatr Anaesth /01/2017 UZ Leuven December 44

45 Health care provider 11/01/2017 UZ Leuven December 45

46 Providor-Tailored Intervention for Perioperative Stress Multimodal training program Specialized training seminars didactic information video modeling in vivo coaching Martin, S. R., et al. Anesthesiology, /01/2017 UZ Leuven December 46

47 increases in rates of desired behaviors reductions in rates of undesired behaviors nurses were highly malleable to the training anxiety level of the children decreased 11/01/2017 UZ Leuven December 47

48 Alternative interventions 11/01/2017 UZ Leuven December 48

49 Alternative interventions parental acupuncture clown doctors hypnosis low sensory stimulation hand-held video games maybe helpful in reducing children s anxiety and improving their cooperation Manyande, A., et al. Cochrane Database Syst Rev /01/2017 UZ Leuven December 49

50 Alternative interventions Streamed video clips Cartoon distraction Is an effective method of reducing anxiety Mifflin, et al. Anesth Analg 2012 Lee, et al. Anesth analg 2012 UZ Leuven December 11/01/

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52 Alternative interventions Tablet-based interactive distraction (TBID) vs oral midazolam to minimize perioperative anxiety in pediatric patients Treating perioperative anxiety and pain in children: a tailored and innovative approach - Web-based Seiden, et al. Padiatric Anesth 2014 Fortier, et al. Pediatric Aesth /01/2017 UZ Leuven December 52

53 Alternative interventions Other potential areas for future research environmental interventions equipment modification social interventions, including communication Manyande, et al. Cochrane Database Syst Rev /01/2017 UZ Leuven December 53

54 Pediatric Anesthesia Teams Use Sweet Smells to Calm Preoperative Patients 11/01/2017 UZ Leuven December 54

55 Conclusions (1) minimize psychological trauma related to anesthesia and surgery could be predicted to some extent hospital-related stress cannot be focused on the induction alone pyramid of increasing preparation programs not all children need full application of all methods (only a few children require a psychologist) for most of the children distress, anxiety and fear associated with anesthesia is transient 11/01/2017 UZ Leuven December 55

56 Conclusions (2) shaping and exposure (i.e. practise with the anesthesia mask) parental use of distraction enhancement of parental self-efficacy avoid distress promoting behavior health care provider training streamed video clips in the OR, tablets web-based development environment and equipment modification maybe consider premedication in 6 months to 4 years old (these children are less likely to cope unless the anesthesiologist knows how to handle them) 11/01/2017 UZ Leuven December 56

57 FAMILY-CENTERED PEDIATRIC PERIOPERATIVE CARE Chorney, et al. Anesthesiology /01/2017 UZ Leuven December 57

58 Thank you for your attention! 11/01/2017 UZ Leuven December 58